Provider Demographics
NPI:1225895972
Name:TAYLOR, TAMIETRA
Entity Type:Individual
Prefix:
First Name:TAMIETRA
Middle Name:
Last Name:TAYLOR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8302 GREYSTONE CV
Mailing Address - Street 2:
Mailing Address - City:ALEXANDER
Mailing Address - State:AR
Mailing Address - Zip Code:72002-8319
Mailing Address - Country:US
Mailing Address - Phone:501-647-2072
Mailing Address - Fax:
Practice Address - Street 1:8302 GREYSTONE CV
Practice Address - Street 2:
Practice Address - City:ALEXANDER
Practice Address - State:AR
Practice Address - Zip Code:72002-8319
Practice Address - Country:US
Practice Address - Phone:501-647-2072
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-29
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARAR58793747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR306874732Medicaid